Asthma and the unified airway.

Inflammatory processes of the upper and lower airway commonly co-exist. Patients with upper respiratory illnesses such as allergic rhinitis and acute and chronic rhinosinusitis often present to both otolaryngologists and primary care physicians for treatment of their symptoms of nasal and sinus disease. These patients often have concurrent lower respiratory illnesses such as asthma that may be contributing to their overall symptoms and quality of life. Unfortunately, asthma frequently remains undiagnosed in this population. It was the objective of this paper to examine the relationship between upper respiratory illnesses such as rhinitis and rhinosinusitis and lower respiratory illnesses such as asthma, and to provide a framework for primary care and specialty physicians to approach these illnesses as a spectrum of inflammatory disease. The present manuscript was developed by a multidisciplinary workgroup sponsored by the American Academy of Otolaryngic Allergy. Health care providers in various specialties contributed to the manuscript through preparation of written materials and through participation in a panel discussion held in August 2006. Each author was tasked with reviewing a specific content area and preparing a written summary for inclusion in this final document. Respiratory inflammation commonly affects both the upper and lower respiratory tracts, often concurrently. Physicians who are treating patients with symptoms of allergic rhinitis and rhinosinusitis must be vigilant to the presence of asthma among these patients. Appropriate diagnostic methods should be used to identify individuals with concurrent respiratory illnesses, and comprehensive treatment should be instituted to reduce symptoms and improve quality of life.

Executive summary: asthma and the unified airway.

Asthma is a common comorbid disorder that will be seen by otolaryngologists in their treatment of patients with rhinitis, rhinosinusitis, and otitis media. Among otolaryngologists, however, a diagnosis of asthma is infrequently considered in this patient population. Otolaryngologists, however, may be in an important position to recognize this potential diagnosis and provide treatment or appropriate referral. To further develop this relationship among upper and lower airway inflammation, and to provide important information to otolaryngologists regarding this relationship, a multidisciplinary workgroup was impaneled by the American Academy of Otolaryngologic Allergy in August 2006. The full report of this meeting is published separately as a Supplement to Otolaryngology-Head and Neck Surgery. This Executive Summary provides a brief synopsis of that document, with a focus on comorbid respiratory inflammation for otolaryngologists. In the treatment of their patients with allergic rhinitis and rhinosinusitis, otolaryngologists must be aware of the possible presence of asthma so that appropriate treatment and/or referral can be initiated. The impact of this practice will allow more comprehensive treatment of patients with upper and lower airway disease, and will improve patient symptoms, function, and quality of life.

Localization of biotinidase in the brain: implications for its role in hearing loss in biotinidase deficiency.

Biotinidase deficiency is an autosomal recessively inherited disorder characterized by neurological and cutaneous features, including sensorineural hearing loss. Although many of the features of the disorder are reversible following treatment with biotin, the hearing loss appears to be irreversible. To better characterize the nature of the hearing loss in this disorder, location of the expression and presence of biotinidase within the brain was examined using Northern blot analysis, in vitro hybridization of a cDNA panel, and immunohistochemical staining. Results indicate low, but detectable expression of biotinidase throughout the brain, but increased concentrations of biotinidase within the dorsal cochlear nucleus, ventral cochlear nucleus, and superior olivary complex of the brainstem, as well as, in the hair cells and spiral ganglion of the cochlea. These findings suggest that biotinidase and possibly biotin plays an important role in hearing.

Immunohistochemical localization of calcium-binding proteins in the brainstem vestibular nuclei of the jaundiced Gunn rat.

Vestibular gaze and postural abnormalities are major sequelae of neonatal hyperbilirubinemia. The sites and cellular effects of bilirubin toxicity in the brainstem vestibular pathway are not easily detected. Since altered intracellular calcium homeostasis may play a role in neuronal cell death, we hypothesized that altered expression of calcium-binding proteins may occur in brainstem vestibular nuclei of the classic animal model of bilirubin neurotoxicity. The expression of the calcium-binding proteins calbindin-D28k and parvalbumin in the brainstem vestibular pathways and cerebellum of homozygous recessive jaundiced (jj) Gunn rats was examined by light microscopy and immunohistochemistry at 18 days postnatally and compared to the findings obtained from age-matched non-jaundiced heterozygous (Nj) littermate controls. Jaundiced animals exhibited decreased parvalbumin immunoreactivity specifically in synaptic inputs to superior, medial, and inferior vestibular nuclei, and to oculomotor and trochlear nuclei, whereas the neurons retained their normal immunoreactivity. Jaundiced animals also demonstrated a decrease in calbindin expression in the lateral vestibular nuclei and a paucity of calbindin-immunoreactive synaptic endings on the somata of Deiters' neurons. The involved regions are related to the control of the vestibulo-ocular and vestibulospinal reflexes. Decreased expression of calcium-binding proteins in brainstem vestibular neurons may relate to the vestibulo-ocular and vestibulospinal dysfunction seen with clinical kernicterus, and may provide a sensitive new way to assess bilirubin toxicity in the vestibular system.

Classification and epidemiology of tinnitus.

One third of all adults report experiencing tinnitus at some time in their lives. Ten percent to 15% have prolonged tinnitus requiring medical evaluation. Classification of tinnitus requires a thorough history and physical examination, supplemented by appropriate diagnostic tests. Tinnitus can be categorized according to its qualities (as described by the patient and matched on the audiometer) and its clinical type (as suggested by probable etiology). Audiologic testing, tinnitus analysis, and occasional radiologic studies assist with classification and direction of treatment planning. The THI is another method of classification that can facilitate the precise monitoring of a patient's progress. By using these tools and standardizing the language, tinnitus studies around the world can become more comparable and patients can be better monitored for treatment response.

Allergic skin disease.

The two most common allergic skin diseases in the world are often the least familiar to practicing surgeons: atopic dermatitis and contact dermatitis. When unrecognized, these disorders can cause great discomfort and decreased quality of life. This is only made worse by a surgical procedure which can exacerbate the disease process. Through proper recognition, management, and peri-surgical prophylaxis flares of these diseases can be avoided, leading to decreased morbidity and improved patient satisfaction. This article summarizes the pathophysiology and management of both atopic and contact dermatitis, with attention to implications for the surgeon.